Transporting an Arrest, Question on a Call

[ghost02]

Hey guys,

I had a question on a call I was on. I'm a Basic in FTO, so I am trying to figure the judgement calls out.

I have already looked at the following thread, but it didn't really clear all my questions up: http://emtlife.com/threads/no-cpr-is-better-than-moving-cpr-true-or-false.32320/

We had a patient who was having an MI, while we are moving her via stair-chair she codes. We moved her to the stretcher and then went L&S to closest Hospital with a travel time of appox. 7 minutes with resuscitation efforts enroute.

According to alot of what I have read, it would have been best to stay on scene and do the full workup. That doesn't really make much sense to me, as we were already in the process of moving the patient to the Ambulance, and the transport time was so short, so it seems that it would be better to get the patient to definitive care. I can understand if the patient coded prior to our arrival, but not after we were moving the patient to the Ambulance. Does the fact that it was a witnessed arrest change anything in terms of transport?

So my question is, when is it appropriate to transport a code without ROSC, and when is it not?

 

[DesertMedic66]

Full arrests are run the exact same in the hospital and in the field. There is no magic full arrest God that makes the hospital bring a patient back (there are some very limited scenarios where the hospital can do more but they are very limited).

While everyone is going to have an opinion on when you should or should not transport a full arrest patient in the end it's going to come down to your protocols and med control.

 

[chaz90]

Ask yourself what gives you the best chance to get ROSC. If she codes in the stair chair, go whichever way gets you to level ground faster (down a floor or back up) and immediately defibrillate if it's a shockable rhythm. Witnessed arrests secondary to MIs are incredibly likely to be VF, so these are the codes that are most viable. Get some shocks on board ASAP, begin high quality CPR on scene, and you'll hopefully get ROSC quite quickly and then be able to transport.

I've seen a code in a stair chair that went terribly. You keep moving, it takes a while, no defibrillation or compressions are possible in the stair chair, and by the time the patient is on the stretcher and in the ambulance you've failed to treat a witnessed arrest for several minutes.

Definitive care for a witnessed arrest should not be thought of in terms of short transport times and running to a hospital. No definitive care from anyone (bar a few rare, rare scenarios) is going to happen until this patient has a perfusing heart beat again. The single best thing you can do for her is provide optimal care to regain that pulse, which in this case means working on scene. Whether BLS or ALS, you are equipped with a defibrillator and hands, which is what she needs.

To be honest, this is an issue I struggle to impress upon local BLS as well. Even some of my ALS coworkers sometimes try to load and go with codes if the hospital is close by. Locally at least, I think EMS does a better job of working a code than some of the atrocious pauses in compressions and slow shocks I've seen in EDs.

 

[Chewy20]

I would have immediately taken her off the chair and started compressions with a pit-crew. Time was wasted getting her to the stretcher, then moved over to the stretcher, then loaded, THEN starting compressions. Usually better off to stay on scene until the PT is either stable enough to be transported or can be pronounced. Staying on scene usually means more room to work, and a solid surface that isn't turning and moving. Also when you arrive to the hospital CPR may have been interfered with again while getting her out and so forth. This is something you need to talk to your supervisors about as different companies expect you to do things their way. I'm guessing this is your first code or close to it. Keep up the good work.

 

[MonkeyArrow]

Can you be more specific about what type of MI? If it was a STEMI, I would definitely transport, assuming that the hospital is PCI capable. IMHO, the reason why you continue compressions is to maintain artificial blood flow until you can solve the reason why the blood has stopped flowing (heart has stopped beating). If it's a STEMI, the only way the pt. will survive is if they get the coronaries cleaned out at the cath lab. Of course, this is assuming that your cath lab performs intervention with CPR in progress.

 

[chaz90]

Can you be more specific about what type of MI? If it was a STEMI, I would definitely transport, assuming that the hospital is PCI capable. IMHO, the reason why you continue compressions is to maintain artificial blood flow until you can solve the reason why the blood has stopped flowing (heart has stopped beating). If it's a STEMI, the only way the pt. will survive is if they get the coronaries cleaned out at the cath lab. Of course, this is assuming that your cath lab performs intervention with CPR in progress.

Just because PCI may be needed doesn't mean ROSC is impossible without. ROSC is frequently achieved during active STEMIs without thrombolytics or PCI. There aren't a lot of hospitals outside of major academic medical centers that are able to take a patient to the Cath lab with CPR in progress. In all likelihood, the ED would run this call identically to how it should be run in the field.

 

[ghost02]

I do not know the type of MI unfortunately. I realize now that I should find that out from my preceptor for all EKG's from now on, and figure out what he tells me ;D. I do know that the patient was in PEA during transport.

Also, it was my first code.

 

[TRSpeed]

We can all say whatever we want but in the end. We all know if we had this same scenario, all would end up transporting this patient to a PCI capable hospital asap. Of coarse with defibrillation and CPR etc. You knew what the pts problem was, you were most likely a minute or two from the ambulance with a witnessed arrest in your hands. I don't think many people would end up terminating efforts on your patient after some rounds at the bottom of some stairs.

 

[MonkeyArrow]

Just because PCI may be needed doesn't mean ROSC is impossible without. ROSC is frequently achieved during active STEMIs without thrombolytics or PCI. There aren't a lot of hospitals outside of major academic medical centers that are able to take a patient to the Cath lab with CPR in progress. In all likelihood, the ED would run this call identically to how it should be run in the field.

It's very location specific. Our approx. 500 bed territory care center, who is not associated with any med school and is not a trauma center, does PCI with CPR in progress. Also, the incidence of re-arrest after initial ROSC is very high since the pt. still requires definitive care to relieve the blockages in the arteries, whether it be PCI or lytics. By delaying transport on someone who requires such treatment which cannot be provided in the field, you are only decreasing the likelihood that said treatments will work once administered. IDK, maybe I'm just spoiled with the hospital that we transport to...

 

[LACoGurneyjockey]

My personal opinion is to work the arrest on scene, and if no ROSC with shocks, drugs, and an airway in place after 20 minutes get with med control and call it. My protocol makes that a little more difficult.
Every medic I've brought the question of transport or work on scene to has had a fairly dismal answer. Something along the lines of it's easier to shock, establish IV access, get a tube in place on scene, and transport, because they'd rather let a doctor call it at the ER than have to do it themselves with med control.
It seems pretty well established that quality compressions cannot be achieved by a FFs one handed efforts on a moving backboard, or while bouncing down the road at 70.
I can see plenty of situations where load and go will benefit the patient, but the vast majority of the time I believe in working them on scene until you/med control is comfortable calling it.
As others have said, there's nothing special a hospital can do for the vast majority of arrests, and transporting them just reduces the efficacy of resuscitation efforts after your 10-15min on scene time.
Unfortunately, as the EMT on an ALS unit that's not your decision to make, frustrating as it may be.
The only real "save" I've had in 2 years was a witnessed arrest, coworkers started quality compressions, and we shocked into sinus tach immediately upon our arrival. He had a LBBB, 15 minutes of down time, and signed his Medicare signature form at the ER with a GCS of 15. Early compressions, early difibrillation, that's what works. Not code 3 transport so an MD can watch the same ACLS you just did for another 10 minutes and call it.

 

[chaz90]

It's very location specific. Our approx. 500 bed territory care center, who is not associated with any med school and is not a trauma center, does PCI with CPR in progress. Also, the incidence of re-arrest after initial ROSC is very high since the pt. still requires definitive care to relieve the blockages in the arteries, whether it be PCI or lytics. By delaying transport on someone who requires such treatment which cannot be provided in the field, you are only decreasing the likelihood that said treatments will work once administered. IDK, maybe I'm just spoiled with the hospital that we transport to...

Agreed that certain hospital interventions are location specific, but good manual compressions are never possible in a moving ambulance. Yep, the patient might rearrest, but they might not. Get ROSC on scene so there's actually effective blood flow during transport rather than poorly managed compressions as someone rides the stretcher in to the ED.

I think my big thing is that an MI was the initial problem, but that has now been superseded by a cardiac arrest. Fix the immediate life threat as you see them and are able to, which in this case means trying to get the patient's heart beating so the original MI can be treated.

 

[LACoGurneyjockey]

Agreed that certain hospital interventions are location specific, but good manual compressions are never possible in a moving ambulance. Yep, the patient might rearrest, but they might not. Get ROSC on scene so there's actually effective blood flow during transport rather than poorly managed compressions as someone rides the stretcher in to the ED.

I think my big thing is that an MI was the initial problem, but that has now been superseded by a cardiac arrest. Fix the immediate life threat as you see them and are able to, which in this case means trying to get the patient's heart beating so the original MI can be treated.

Even if you do transport to a STEMI center, that patient's not going to the cath lab in cardiac arrest. The ED is going to do the same thing you're doing in the field, treat the arrest, then treat the underlying cause.

 

[chaz90]

Even if you do transport to a STEMI center, that patient's not going to the cath lab in cardiac arrest. The ED is going to do the same thing you're doing in the field, treat the arrest, then treat the underlying cause.

Well, I'm trying to make the same point you are, but there are facilities that take cardiac arrest patients to the cath lab with compressions underway. Monkeyarrow related his local hospital is one that will do this.

 

[LACoGurneyjockey]

Yep, and I was agreeing with you in an unnecessarily argumentative way, but I really should read all the replies before I get all excited and what not... Never heard of a PCI facility cathing a patient with CPR in progress, but now you got me interested.
Monkeyarrow, you're definitely spoiled

 

[MrJones]

My general rule of thumb - protocols permitting, I do not put a dead person in my ambulance. Dying enroute, of course, is a horse of a different color.

 

[MonkeyArrow]

@chaz90 @LACoGurneyjockey So I guess this is the real "what if?" question... If your hospital is capable of performing PCI with CPR in progress, do you still transport L&S when the pt. is coding on scene with a confirmed MI as the etiology?

At this point, I guess the matrix becomes

• Will resolving the MI via PCI also resolve the cardiac arrest?
• Can you effectively perform CPR en route to perfuse the brain so that when the pt. has recanalization, they will not be brain dead?
• Can you perform said CPR while endangering you or your patient's safety? (although more you and your partner at this point...)

 

[chaz90]

@chaz90 @LACoGurneyjockey So I guess this is the real "what if?" question... If your hospital is capable of performing PCI with CPR in progress, do you still transport L&S when the pt. is coding on scene with a confirmed MI as the etiology?

At this point, I guess the matrix becomes

• Will resolving the MI via PCI also resolve the cardiac arrest?
• Can you effectively perform CPR en route to perfuse the brain so that when the pt. has recanalization, they will not be brain dead?
• Can you perform said CPR while endangering you or your patient's safety? (although more you and your partner at this point...)

This does change things slightly. For me, the answer would still be to attempt working on scene for ROSC for some amount of time. I still don't believe manual compressions in a moving ambulance for a 7 minute transport and various delays moving at the hospital give this patient a fair chance at neurologically intact survival.

In my perfect world with some sort of mechanically assisted CPR device available and this aggressive PCI center nearby, I would transport with ongoing mechanical compressions if the patient continued in refractory cardiac arrest after initial treatment on scene.

To summarize my answers to your questions:

1. Presumably, or at least hopefully. Depends on a ton of factors, and clearly tons more research is needed, but at least theoretically that would be the goal.

2. No, I don't believe this is possible with various times moving the patient and driving around with manual compressions. Factor in a likely excited driver moving too quickly and it just makes it more difficult.

3. I think it causes an unnecessary risk to anyone attempting manual compressions during transport. Depends on the driver, but I think there's a better way than exposing ourselves to this risk.

 

[LACoGurneyjockey]

1. Will they spontaneously begin perfusing in the cath lab, probably not, but it's giving them a realistic chance at ROSC with continued ACLS.
2. No, I don't think you can maintain quality compressions while moving a patient. Enroute, it's debatable and situation dependent. Down a solid surface street with smooth driving, I bet you could. Down a dirt road or with Ricky Rescue hauling at 80mph down the boulevard, prolly not. But the potential of fixing the cause of their arrest is worth a period of interrupted/low quality compressions to move/load the patient, in my woefully undereducated opinion.
3. We do it all the time without such a nice shiny PCI facility. I don't agree with it, but I'd be no more uncomfortable doing it for a better reason than we are now.

It's something I've never thought about, mainly because I didn't know it was being done.
I just feel like in most situations there is no way to confirm MI as the cause of arrest. Now do I have a patient with a pulse and a 12 lead showing MI who arrests in front of me? Absolutely I'm transporting to your miracle cath lab with CPR in progress, assuming it's also my nearest receiving. I can't fix that etiology, but they can. Would I load and go, probably not. But I'll get shocks, drugs, and a tube on board and book it down the road with the best quality compressions I can manage. This is where I go and bug my ops manager for a Lucas/Autopulse.
Is this facility your nearest receiving throughout your coverage area? Can you bypass a closer, less capable ED in a full arrest with suspected cardiac origin to transport to the cath lab with CPR in progress?

 

[ZombieEMT]

I agree that CPR should have been immediately administered on scene, prior to transport. Effective CPR and used of the AED are the most important things in treating a patient in cardiac arrest. The hospital does exactly the same. It is important to provide quick and quality CPR with a pit crew approach on scene, then to attempt resuscitation in the back of a moving ambulance. Do a Google search on Seattles approach to CPR, they have the highest ROSC in the county.

 

[mycrofft]

We can all say whatever we want but in the end. We all know if we had this same scenario, all would end up transporting this patient to a PCI capable hospital asap. Of coarse with defibrillation and CPR etc. You knew what the pts problem was, you were most likely a minute or two from the ambulance with a witnessed arrest in your hands. I don't think many people would end up terminating efforts on your patient after some rounds at the bottom of some stairs.

There you have it.
My axiom is :"No one was ever transferred from a hospital to an ambulance for better care".
One corrolary to "stay and play" is more cases where field techs determine death in the field rather than it occuring or being called in a hosital.